Key result
CT-targeted LV pacing yields ~233% greater acute hemodynamic response versus nontarget segments during CRT upgrades.
Why the study?
Optimal LV lead positioning determines CRT response, leading investigators to evaluate the feasibility of intraprocedural integration of cardiac CT to guide LV lead implantation for CRT upgrades.
Does intraprocedural integration of cardiac CT to guide LV lead implantation improve acute hemodynamics and reverse remodeling in patients undergoing CRT upgrades?
Does intraprocedural integration of cardiac CT to guide LV lead implantation improve acute hemodynamics and reverse remodeling in patients undergoing CRT upgrades?
Absolute Event Rate: 83.3% vs 25%
p-value: p=0.012
Intraprocedural integration of cardiac CT to guide LV lead placement during CRT upgrades is feasible and associated with superior acute hemodynamics when pacing in target segments.
May support CT-guided LV lead placement in CRT upgrades; hypothesis-generating for reverse remodeling and requires prospective validation.
Background Optimal positioning of the left ventricular (LV) lead is an important determinant of cardiac resynchronization therapy (CRT) response. Objective Evaluate the feasibility of intraprocedural integration of cardiac computed tomography (CT) to guide LV lead implantation for CRT upgrades. Methods Patients undergoing LV lead upgrade underwent ECG‐gated cardiac CT dyssynchrony and LV scar assessment. Target American Heart Association segment selection was determined using latest non‐scarred mechanically activating segments overlaid onto real‐time fluoroscopy with image co‐registration to guide optimal LV lead implantation. Hemodynamic validation was performed using a pressure wire in the LV cavity (dP/dtmax)). Results 18 patients (male 94%, 55.6% ischemic cardiomyopathy) with RV pacing burden 60.0 ± 43.7% and mean QRS duration 154 ± 30 ms underwent cardiac CT. 10/10 ischemic patients had CT evidence of scar and these segments were excluded as targets. Seventeen out of 18 (94%) patients underwent successful LV lead implantation with delivery to the CT target segment in 15 out of 18 (83%) of patients. Acute hemodynamic response (dP/dtmax ≥ 10%) was superior with LV stimulation in CT target versus nontarget segments (83.3% vs. 25.0%; p = .012). Reverse remodeling at 6 months (LV end‐systolic volume improvement ≥15%) occurred in 60% of subjects (4/8 [50.0%] ischemic cardiomyopathy vs. 5/7 [71.4%] nonischemic cardiomyopathy, p = .608). Conclusion Intraprocedural integration of cardiac CT to guide optimal LV lead placement is feasible with superior hemodynamics when pacing in CT target segments and favorable volumetric response rates, despite a high proportion of patients with ischemic cardiomyopathy. Multicentre, randomized controlled studies are needed to evaluate whether intraprocedural integration of cardiac CT is superior to standard care.
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Gould et al. (2021) studied Heart failure requiring CRT upgrade (n=18). LV stimulation in CT target segments vs. LV stimulation in nontarget segments was evaluated on Acute hemodynamic response (dP/dtmax ≥ 10%) (p=0.012). Pacing in CT target segments yielded a superior acute hemodynamic response compared to nontarget segments (83.3% vs 25.0%; p=0.012) during LV lead implantation for CRT upgrades.
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